Provider Demographics
NPI:1558852046
Name:RYAN, LISA (PTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12322 NW 54TH CT
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-3410
Mailing Address - Country:US
Mailing Address - Phone:954-218-7167
Mailing Address - Fax:
Practice Address - Street 1:4988 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33351-5748
Practice Address - Country:US
Practice Address - Phone:954-746-7230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27466225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant